M a c do n ald, S t e p h e n J (202 0) The r a p e u tic Ins ti t u tions of Violenc e: conc e p t u alising t h e biog r a p hic al n a r r a tive s of m e n t al h e al t h s e rvice u s e r s/s u rvivors a cc es sin g long t e r m ‘tr e a t m e n t’ in E n gla n d. Jou r n al of C ri minological Res e a r c h, Policy a n d P r a c tice, a h e a d. p . 1 . ISS N 2 0 5 6-3 8 4 1

Downloa d e d fro m: h t t p://su r e . s u n d e rl a n d. ac.uk/id/e p rin t /12 2 5 9/

U s a g e g u i d e l i n e s

Ple a s e r ef e r to t h e u s a g e g uid elines a t h t t p://su r e . s u n d e rl a n d. ac.uk/policies.h t ml o r al t e r n a tively con t ac t s u r e@s u n d e rl a n d. ac.uk.

Therapeutic Institutions of Violence: conceptualising the biographical narratives of mental

health service users/survivors accessing long term ‘treatment’ in England

To cite this article: Macdonald, S. J. (2020) Therapeutic Institutions of Violence: conceptualising the biographical narratives of mental health service users/survivors accessing long term ‘treatment’ in England. Journal of Criminological Research, Policy and Practice: DOI (10.1108/JCRPP-02-2020-0027)

Purpose: This article aims to conceptualise the residential and psychiatric hospital as a space

where criminality and social harms can emerge. Due to recent media scandals over the past

10 years concerning privately owned hospitals, this study examines the lived experiences of

service users/survivors, family members and practitioners to examine historic and

contemporary encounters of distress and violence in hospital settings.

Methodology: The study consists of 16 biographical accounts exploring issues of

dehumanising and harmful practices, such as practices of restraint and rituals of coercive

violence. A Biographical Methodology has been employed to analyse the life stories of service

users/survivors (n = 9), family members (n = 3), and professional health care employees (n =

4). Service users/survivors in this study have experienced over 40 years of short-term and

long-term periods of hospitalisation.

Findings: The study discovered that institutional forms of violence had changed after the de-

institutionalisation of care. Practitioners recalled comprehensive experiences of violence

within historic mental hospitals, although violence that may be considered criminal appeared

to disappear from hospitals after the Mental Health Act (1983). These reports of criminal

violence and coercive abuse appeared to be replaced with dehumanising and harmful

procedures, such as practices of restraint.

Originality: The data findings offer a unique interpretation, both historical and contemporary,

of dehumanising psychiatric rituals experienced by service users/survivors, which are relevant

to criminology and MAD Studies. The article concludes by challenging oppressive psychiatric

‘harms’ to promote social justice for service users/survivors currently being ‘treated’ within

the contemporary psychiatric system.

The article intends to conceptualise residential and psychiatric hospitals as a space

where criminality and social harms can emerge.

The three aims of the study examined risk factors concerning criminality and social

harms, oppressive and harmful practices within hospitals, and evidence that violence

occurs within these institutionalised settings.

The study discovered that institutional forms of violence had changed after the de-

institutionalisation of care.

These reports of violence include dehumanising attitudes, practices of restraint, and

coercive abuse.

The data findings offer a unique interpretation, both historical and contemporary, of

dehumanising psychiatric rituals experienced by service users/survivors, which are

relevant to criminology.

Introduction

Since 2011, the British media have reported numerous incidents concerning institutional

violence within residential care homes and privately commissioned hospitals (Bubb 2014).

Examples of violence that have been exposed in these institutions are Winterbourne View

Hospital Bristol, Ash Count Hospital London, Purbeck Care Home Dorset, Muckamore Abbey

Hospital Belfast and Whorlton Hall Hospital County Durham. In each case practices of systemic

physical violence and psychological abuse where exposed and arrests and prosecutions of

employees were made (Bubb 2014; Murphy 2019). The first example of abuse was broadcast

by the BBC’s Panorama programme from within the psychiatric hospital of Winterbourne

View (Flynn and Citarella 2013). Staff at this hospital were secretly filmed, and this revealed

the systemic use of violence, dehumanising psychological abuse of patients, and the overuse

of restraint. Patients were enticed by staff to react violently so restraints could be justified

within these hospital spaces (Flynn and Citarella 2013). Although there have been a significant

number of scandals concerning these mental health hospitals, criminology as a discipline

appears to have paid little attention to these abuses.

This wave of recent hospital scandals is not a new occurrence as the BBC in the 1960s, 1970s

and 1980s exposed similar incidence of abuse concerning the then NHS mental hospitals

(Jessel and Boulding 2010). These hospitals were later decommissioned in the 1980s partly

because of some of these exposures (Martin 1985; Cummins 2010). Thus this article proposes

to examine the practices of institutional violence by presenting the biographical accounts of

patients, practitioners, and family members who have visited lived and worked in a range of

psychiatric institutions over the past 40 years. The data findings will illustrate that although

there has been a move to deinstitutionalise mental health services, for participants in this

study their life histories seem to have been dominated by a range of psychiatric institutions,

from historic mental hospitals to contemporary short-stay psychiatric hospitals to residential

care homes. Within the data analysis, the key issue is not regarding criminal violence

occurring within these hospitals, but dehumanising and harmful practices concerning the use

of restraint, particularly in contemporary residential care homes. Thus this article will present

evidence of dehumanising attitudes and practices by staff within these institutions of care,

which could reveal a space for systemic forms of violence to occur within these hospital

environments (Martin 1985; Cummins 2010; Flynn and Citarella 2013).

Criminology and Disability/MAD Studies

It should be noted that the author has employed Disability Theory, deriving significant

influence from MAD Studies scholarship, to analyse the data presented in this study (Dowse

et al. 2008; Macdonald 2012; 2015; Voronka 2013). The use of Disability Theory within

criminology was first employed by Leanne Dowse, Eileen Baldry, and Philip Snoyman in their

2008 article entitled ‘Disabling Criminology’. Since the publication of this article, disability

scholars (see Sherry 2010; Roulstone et al. 2013) and criminologists (see Macdonald 2012;

2015) have applied Disability Theory within their work on victimisation and criminality. To

conceptualise how Disability Theory can be applied within a criminological context we need

to examine the origins of Disability Studies and the emergence of MAD Studies. Disability

Studies in the UK emerged from a grassroots political movement which led to the formulation

of a social constructionist approach of disability (Shakespeare 2013). Disability Studies

developed a critique of the bio-medical model that dominates professional practice and

pathologises social problems that affect disabled people’s lives (Barnes 2019). Early Disability

Studies scholars suggest that the problems people experience are not due to their biological

limitations but due to environmental factors that prevent disabled people from interacting or

participating in general social life (Oliver 2009; Barnes 2019).

From this perspective, Disability Studies offers an alternative constructionist approach to

conceptualise disability and impairment. Thus, the problems that disabled people experience

are not just due to functional limitations, i.e. an impairment effect, but due to constructed

environmental barriers that prevent people with biological, sensory, neurological, cognitive,

or mental health conditions, from fully participating in social life. At the core of Disability

Studies is the importance of service user voices which construct knowledge concerning the

experiences of disability (Oliver 2009). Listening to service user experiences is of significant

importance as these stories can often illustrate oppressive, harmful (and sometimes criminal)

effects of professional practice. One of the most noteworthy scholars who have applied

Disability Theory to the experiences of mental health is Peter Beresford. For Beresford (2004),

Disability Studies has provided a successful framework for challenging the harmful effects of

the bio-medical dominance within professional practice and in academia.

Beresford (2004) suggests that Disability Theory offers a structural analysis that recognises

and challenges discriminatory practices, social stigmatisation, unemployment, forced

hospitalisation and institutional harms. Yet he also concedes that Disability Studies does not

entirely represent the voices of mental health service users/survivors, as this approach was

developed out of concerns over ‘disability’ rather than ‘mental distress’. Within his research

on mental health, many service users/survivors reject the term ‘disability’. To represent

service user/survivor voices Beresford suggested the formulation of a specific theoretical

framework within Disability Studies to conceptualise experiences of mental distress

(Beresford 2004). Due to Beresford’s research numerous scholars, such as Richard Ingram,

Brenda LeFrançois, and more recently Jasna Russo, have helped to formulate the concept of

MAD Studies as a sub-discipline of Disability Studies. From LeFrançois et al.’s (2013)

perspective, MAD Studies utilises knowledge from Disability Studies, the anti-psychiatry

movement, and Mad Pride activism to critically evaluate the construction of ‘mental illness’

and to reclaim ‘madness’ from a service user’s standpoint.

From a MAD Studies perspective, the psychiatric system is not scientifically neutral but

ideologically driven and needs to be critically examined and held accountable for their

oppressive practices (Macdonald, et al. 2018). MAD Studies is a unique examination of

psychiatry and psychiatric services; for example, there are critiques of the pathological

construction of mental ‘illness’, the use of medication as a system of social control, the legal

acceptance of forced institutionalised care, and the continual use of hospital restraints and

Electroconvulsive Therapy. As Filson (2016: 46) illustrates, the psychiatric system often

misinterprets service users’ stories of ‘what happened to us’ as ‘what is wrong with us’. As

Filson explains, the psychiatric system has ownership over the construction of knowledge that

defines professional practices under the discourse of ‘medical treatment’. Thus, by applying

a Disability/MAD Studies approach within criminology, this study aims to analyse the lived

experiences of service users/survivors and their allies to conceptualise oppressive and

harmful practices by presenting examples of routine institutional violence within mental

health services.

Hospitalisation, Restraint and Violence

To examine criminal, dehumanising and harmful practices within hospitals and care homes

the author has drawn on the emergence of theoretical ideas from within critical criminology

and MAD Studies (see Dowse et al. 2008). This is to offer criminology an alternative critical

perspective to mental health other than that of the dominant forensic psychological, i.e. bio-

medical, approaches which define mental ‘illness’ within criminal justice practices. This

conceptualisation of psychiatric treatments as harmful rather than therapeutic is a common

theme that has emerged from critical approaches to psychiatric practices from disciplines

such as critical psychiatry, the anti-psychiatry movement, and MAD Studies (Szasz 2007;

LeFrançois et al. 2013; Middleton and Moncrieff 2019). From a bio-medical perspective, there

are countless psychiatric studies which define mental ‘illness’ as a bio-social reality that can

be successfully treated with pharmaceutical interventions (Semple and Smyth 2019),

hospitalisation (Johnstone 1999; Steinert et al. 2000; Walsh 2002) and electroconvulsive

therapy (Fitzgerald et al. 2015; Moeller et al. 2017; Nuninga et al. 2018). Yet critiques have

emerged for MAD Studies scholarship that has questioned the effectiveness of psychiatry’s

biological reductionist methods of treatments (LeFrançois et al. 2013; Weitz 2013; Russo and

Sweeney 2016). As Menzies et al. (2013) suggest, hospital-based psychiatric treatments are

often ineffective and are described by many service users/survivors as harmful, escalating

rather than reducing experiences of mental distress. The extensive use of restraint, forced

hospitalisation and forced medication has been conceptualised as equating to human/civil

rights violations by MAD Studies scholars (Menzies et al. 2013; Weitz 2013; Russo and

Sweeney 2016). From a MAD Studies approach, coercion and biomedical violence are such

controversial topics in the psychiatric care system because forced hospitalisation and the use

of restraint are sanctioned by the State under the Mental Health Act (1983/2007). Thus,

medical and nursing staff presume that biomedical violence is part of their daily working

routines. Although psychiatry and its allied disciplines would suggest that compulsory

measures such as hospitalisation, seclusion and restraint are generally considered to be used

as a last resort to avert acute danger to patients or practitioners, MAD Studies scholars such

as Lee (2013) imply that these practices have an important role in objectifying experiences of

symbolic violence. In a study by Lepping et al. (2016) comparing the use of restraint in four

European countries (Netherlands, Germany, Ireland and the UK), they discovered a relatively

consistent use of officially recorded restraints where up to 9.4% of patients were exposed to

this practice. Yet cultures of restraint were different depending on each country. For example,

the Netherlands and Germany predominantly used the practice of seclusion as a form of

restraint and were less likely to use restraint to force the use of medication due to their

mental health policies (Lepping et al. 2016). Yet within the UK and Ireland practitioners were

more likely to use physical restraint to force the use of medications and to restrict the

movement of service users/survivors to prevent violence (Lepping et al. 2016). Research

conducted on the use of hospital restraints discovered that the more staff engaged in this

practice the more normalised it became, like a routine intervention (Dahan et al. 2018).

The normalisation of restraint has been a significant issue concerning recent media scandals

in private commissioned psychiatric residential hospitals (Flynn and Citarella 2013). As Flynn

and Citarella (2013) illustrate, the first media scandal occurred when an NHS nurse contacted

the BBC to report systemic violence and serious abuse at Winterbourne View Hospital.

Winterbourne View was a privately run hospital that aspired to treat patients with autism and

learning difficulties with behavioural problems (Flynn and Citarella 2013; Bubb 2014). A senior

nurse had reported witnessing bullying, violence and abuse taking place within the hospital

and had reported this to senior management in Castlebeck Care and to the Quality Care

Commission (Bubb 2014). However, his concerns were not taken seriously and Winterbourne

View was subsequently assessed and rated as outstanding by the Quality Care Commission

(Bubb 2014). This led to the nurse contacting the BBC who placed a covert journalist employed

as a care assistant in the hospital. The TV programme broadcast significant scenes of violence

and abuse that occurred within the hospital. In the aftermath of the BBC investigation, 11

staff members acquired criminal convictions and six of these received a custodial sentence

relating to neglect and abuse (Bubb 2014). The UK government conducted a Serious Case

Review and concluded that:

‘(1) too many people had been placed in inpatient services for assessment and treatment and

has stayed there for too long … (2) there was evidence of poor quality of care, care planning

and over-reliance on restraint techniques’ (Department of Health 2014: 3)

After the Serious Case Review was published by the Department of Health, the Care Quality

Commission closed several hospitals that fell short of the standards expected of hospitals and

residential care homes (Bubb 2014; Murphy 2019). However, since this Serious Case Review,

several other instances have appeared through similar investigations by the media, such as

abuse occurring at Ash Count Hospital in London, Purbeck Care Home in Dorset, and

Muckamore Abbey Hospital in Belfast. Yet despite claims by the Care Quality Commission to

have improved their inspection procedures so that another Winterbourne View could not

happen again, the BBC conducted an almost identical investigation into Whorlton Hall

Hospital in 2019 (Lacobucci 2019; Murphy 2019). The undercover reporter filmed almost

identical forms of physical and psychological abuse occurring on the hospital wards (Murphy

2019). Similar to Winterbourne View Hospital there was an overuse of restraints to instigate

violence between patients and staff. These employees are now also currently under

investigation and could face custodial sentences because of the systematic abuse which took

place within this hospital (Lacobucci 2019; Murphy 2019).

Yet, these scandals are not new, as in the 1960s, 1970s and 1980s the BBC also conducted

several investigations into abuse within historical mental hospitals which revealed similar

forms of physical and psychological violence (Jessel and Boulding 2010). These documentaries

revealed systematic physical abuse, the overuse of restraint, and widespread psychological

violence occurring within these institutions. These investigations intersected with the anti-

psychiatry movement which was calling for the end of institutional care for patients with

mental health or learning disabilities (Wall 2017). Following the implementation of the Mental

Health Act (1983), the NHS moved from a model of NHS funded institutional care to that of a

local authority funded community care system. Although in the UK the 1990s have been

celebrated as a period of deinstitutionalisation, many scholars from within the anti-psychiatry

movement and MAD Studies have questioned the success of this policy initiative (Slovenko

2003; Szasz 2005; LeFrançois et al. 2013; Wall 2017; Macdonald et al. 2018). Scholars such as

Szasz (2005) and Macdonald et al. (2018) have suggested that many service users/survivors

with significant mental health conditions have been moved from the large state-owned NHS

hospitals to smaller privately commissioned hospitals. Thus, at the turn-of-the-century, a

number of academics have argued that we are now progressing through a period of trans-

institutionalisation, where privately run psychiatric hospitals and residential care homes are

replacing the old hospitals as a new form of institutional care for people with learning

disabilities and mental health conditions (Slovenko 2003; Szasz 2005; Macdonald et al. 2018).

From a criminological perspective, there has been little focus on the harmful and criminal

behaviours occurring within these institutional spaces. In fact, until recently there has only

been a small number of studies examining associations between disability, mental health and

victimisation (Roulstone et al. 2011; Thomas 2011; Chakraborti and Garland 2015; Macdonald

et al. 2017). Yet as disability is now recognised as a protected characteristic within the

Criminal Justice Act 2003, concerns around disability hate crime have begun to appear within

the literature (Chakraborti and Garland 2015). Unfortunately, as Roulstone et al. (2011)

suggest, although disability is now a protected characteristic within criminal justice policy,

very few prosecutions have applied hate crime legislation, even in extreme cases of murder.

Furthermore, these studies in the field of hate crime have presented some anecdotal

evidence that when acts of violence take place by care staff, these acts of violence are not

dealt with through the criminal justice system but as a human resource issue (Sherry 2010;

Roulstone et al. 2011; Macdonald 2015). Although more research is needed, if these disability

hate crime scholars are correct then care employees are often dismissed from their

employment rather than prosecuted for committing a criminal offence (Sherry 2010;

Roulstone et al. 2011; 2013).

This study will present the narratives of psychiatric service users/survivors to challenge the

notion that these hospitals are safe spaces free of violence and abuse. As it was senior nurses

who were the whistle-blowers in the Winterbourne View and Whorlton Hall hospitals, for this

reason, service user voices will appear alongside voices of practitioners and family members

throughout the findings section. The stories presented in this article will be both historical

and contemporary as patients, family members, and practitioners present narratives from

throughout their life histories. The study presents narratives concerning experiences of

criminal violence and narratives of dehumanising and harmful practices concerning

psychiatric treatments.

Methodology

Design: The article aimed to explore risk factors concerning criminality and social harms,

oppressive and harmful practices within hospitals, and evidence that violence occurs within

these institutionalised settings. The study sought to collect the biographical narratives of

individuals who had experienced severe mental distress in a pre- and post- (de)institutional

care setting (pre- and post-Mental Health Act 1983). By comparing staff and service

user/survivor experiences of long-term care, the study’s intention is to comprehend the lived

experiences of people diagnosed as having a long-term mental health condition in the

contemporary care system. This qualitative study analysed the biographical narratives of

people with mental health conditions by using Wengraf’s (2001) and Bertaux’s (2003)

biographical interviewing technique. Semi-structured interviews lasting between thirty

minutes and two hours were undertaken. Each participant was interviewed in accordance

with the biographical interpretative method of interviewing (Wengraf 2001). Participants

were asked the same single question to induce narrative: ‘Can you please tell me your life

story, with all the events and experiences which you feel relevant, concerning your life?’

(Wengraf 2001: 119). Once participants had discussed their life stories, probing questions

were asked so participants could expand on key aspects of their life stories concerning

experiences of long-term care (Wengraf 2001; Bertaux’s 2003).

However, probing questions were limited to avoid interview bias. Thus, this approach asks

only a small number of focused questions relating to participants’ life experiences. By limiting

questions, this encourages a biographical narrative that gives more control to the participant

and restricts the interviewee from being drawn into a structured hierarchy (Wengraf 2001).

The importance of this kind of interview is that participants were allowed to start their life

story at any historic point they chose, enabling them to speak freely about their position in

relation to the research issue raised. It also allowed participants to translate their own events,

themes and meanings within their own biographies to produce their own narratives.

Sample: In total sixteen participants were interviewed, consisting of nine service

users/survivors, three family members and four psychiatric practitioners. The study employed

a snowball sample where information was sent out to local health and social care services in

the North East to facilitate recruitment. Hence, a number of social work/social care/nursing

practitioners helped the research team promote the study to recruit service user/family

volunteers. Service users/survivors were recruited who had experienced hospitalisation

because of a diagnosed mental health condition. They had all experienced long-term

hospitalisation between 1975 and 2014, which was defined in this study as a minimum period

of six months in the hospital. All service users/survivors were still receiving support due to

their long-term mental health conditions. The age of service users/survivors ranged from 55

to 71 years. All service users/survivors were from a white ethnic background, and more male

service users/survivors (n = 6) were interviewed compared to females (n = 3). Although black

and minority ethnic (BAME) communities are overrepresented in psychiatric services in the

UK, and people from these communities are more likely to be diagnosed with a significant

mental health problem (Bradley 2009), this was not reaffirmed by this study. It should be

noted that the North East of England has the lowest BAME population in England, at 6%

compared to the national average of 19% (ONS 2011). When conducting the research the

team observed that there was a visible lack of BAME service users/survivors accessing

psychiatric residential and community care services, and this may account for why no BAME

service users/survivors volunteered to take part in this study. However, the majority of service

users/survivors were from traditional working-class backgrounds (n = 8), with one participant

defining himself as middle-class.

The psychiatric practitioners had all been employed within a mental hospital before or during

the implementation of the Mental Health Act (1983). They had actively worked in health or

social care services during the 1990s, and had witnessed the transition from hospital-based

care to community care services. With reference to the practitioner group, two female

participants were from a white ethnic background and two male practitioners were from

black/Asian ethnic minority communities. The majority of practitioners described growing up

in a traditional working-class setting (n = 3), with one participant indicating that they were

from a middle-class family. Finally, all family members who were included in the study had

actively visited and/or been part of supporting a close family member throughout their time

as a service user. The age of family members ranged from 50 to 72 years. Two of the female

family members were from a white ethnic background and one male family member was from

a black ethnic minority community. All family members interviewed could be defined as

growing up within a traditional working-class community. Interviews in the study took place

in 2014–2016, in the North East of England.

Analysis: A phenomenological approach was used to interpret the biographical narratives of

participants in this study (Kafai 2013), presenting participants’ interpretations of their life

events to situate the analysis from a service user/survivor perspective in line with MAD

Studies. By employing Daniel Bertaux’s (2003) methodology to service users’/survivors’

biographical narratives, the findings explored personal experiences of social change (Bertaux

2003; Kafai 2013). N-Vivo was used to help organise the data to apply a thematic analysis to

the research. To protect the identities of participants, pseudonyms are used to represent the

narratives of participants throughout the findings section of this article. Full ethical approval

was gained by the research team from the host university as well as through the relevant

health and social care organisations before the research commenced.

Finally, within the data findings, psychiatric services will be defined by a single historical point

identified by the Mental Health Act 1983. This Mental Health Act is a significant milestone in

UK health policy as it ended long-term institutional hospital care. Within the UK this Act of

parliament led to the deinstitutionalisation of psychiatric services and the introduction of

community care services. Therefore, the findings will indicate and compare the time frames

of pre-Mental Health Act as historical, i.e. institutional, and post-Mental Health Act as

contemporary, i.e. community-based care.

Limitations: It should be recognised that no definitive conclusions can be drawn from this

article as there were several limitations to the study. This study was exploratory in nature and

aimed to target a relatively hidden and hard-to-reach community so a small snowball sample

was employed that significantly affects the representativeness of the findings. Due to the

study's small sample size, the research does not claim to be representative of any group

outside of the sample. Experiences of violence were also self-reported, and no objective

measurement was used to categorise these experiences. Thus, participants' knowledge was

accepted as a valid representation of their constructed realities. Although these limitations

exist, and the study cannot and does not attempt to estimate the extent of violence in

residential and psychiatric hospitals, the data presents some interesting theoretical findings

that need further exploration.

Findings: Employment Motivations and Dehumanising Attitudes

In the data findings, a dominant theme emerged relating to risk factors associated with

dehumanising attitudes. Reports of dehumanising attitudes occurred in the narratives of

practitioners, service users/survivors and family members within the historical mental

hospitals (pre-1983), and in contemporary residential care units and psychiatric hospitals

(post-1983). From a practitioner perspective, a fundamental issue that led to increased risk

factors concerning dehumanising attitudes was the motivations and working ethos of staff

employed within these care environments. Both within the pre-1983 and post-1983 care

systems it was narrated that employees had often left low-paid and insecure manual

occupations before relocating into the care industry. A number of practitioner participants

suggested that they had known that the motivation of many of their colleagues working in

the care industry was not because this was a vocation but due to it being secure work in a

region with high levels of unemployment. As Christopher illustrates:

I think a lot of the [people] who worked in the hospital had come from industries

which they didn’t particularly like. So they weren’t necessarily in the hospital

because they had a passion for caring for people, but it was a job that was secure

and they were in control and they didn’t have to do very much. … [Because of this]

there were some people who were absolutely vicious and cruel.

(Christopher: mental health nurse)

Within Christopher’s narrative, he is describing the attitudes of mental health nurses who he

worked alongside in the 1970s and 1980s in historical mental hospitals (pre-1983). However,

similar narratives emerge from practitioners working in contemporary residential care units

and psychiatric hospitals (post-1983). This is illustrated by Joanne, a senior care manager, who

reports similar motivations that she associates with negative working attitudes. Within her

narrative, she often described these employees as ‘uneducated’ and ‘underqualified’. As she

states:

I’ve seen people with crappy attitudes I think is the word I would use, more

uneducated attitudes. You know what I mean? … Where they would think that

they could speak to somebody the way they did because, so if I did see anything

like that, I would pull them and I would say, ‘You can’t talk to somebody like this’.

(Joanne: care manager)

Joanne reports that, because of low wages, finding the right staff who are suitable for care

work is a particular problem in the contemporary system. Joanne, similar to Christopher,

suggests that for some of her employees the choice to work in the care industry was not made

for moral reasons but due to limited employment opportunities. From her perspective, the

disregard for service users’/survivors’ emotional well-being predominantly occurs because

the majority of residential care units have now been privatised and are run for profit. From

her perspective, these organisations are looking for cheap staff and offer limited training. The

implications of having inappropriately motivated and undertrained staff have had significant

consequences, both in the historical and contemporary care systems, with regard to the

emergence of coercive violence.

Narratives of Restraint

Within the data analysis, although glimpses of dehumanising attitudes emerged from within

practitioner narratives, the most normalised oppressive and harmful practices within

hospitals in the pre- and post-1983 care eras refers to the excessive use of restraint. The use

of restraint was portrayed by participants as being the most commonly administered example

of dehumanising and harmful practices employed within hospital settings. Within the

narratives of practitioners, the use of restraint was often justified as a response to violent

incidents with service users/survivors. As Johnny, a mental health nurse reported:

I’ve seen people physically restrained because if somebody is going to be violent

or aggressive or something like that and, you know, there were techniques, and I

was trained in that technique. I’ve been involved in that, but physically abused or

giving, I don’t know, a clip or something, I’ve never seen that.

(Johnny: mental health nurse)

Although Johnny acknowledged the practicality of restraint in his own professional practice,

he did not conceptualise this as a form of violence. In fact, from his perspective using physical

restraint in his professional practice is acceptable (under the Mental Health Act 1983), but he

clearly separated this practice from the use of physical harmful or abusive/criminal

behaviours. Similar to Joanne, Johnny suggested that he had never witnessed any form of

physical abuse other than restraint. From his perspective, the use of restraint is an

unavoidable procedure due to the nature of his work, and this practice is employed primarily

to protect service users/survivors and staff from injury.

In Joanne's narrative, she recounted that it was not until later in her career, after the year

1999, where she was introduced to the practice of restraint (post-1983). This was due to a

change in her employment, as previously she had worked in small residential units where

restraint was never used. Within her narrative, when discovering that restraint was commonly

used within her new care setting she described that this had an emotional impact on her as a

new member of staff:

Yeah. I never realised when I applied for the job that there was going to be

restraint involved. So when they started talking about restraint, I was going, ‘Are

you allowed to do this?’ You know what I mean? My first day was a twelve-hour

shift and again I couldn’t really do anything because I hadn’t had the training. … It

was my first day when I seen a lady restrained and that’s why I said I would never

go back. I thought it was horrific. It was a lady and she tried to attack a member of

staff and she had to be taken to the floor and she was restrained in a T-supine

position which means she was laid on her back in a T position with four members

of staff that restrained [her]. And for a person who’s never seen restraint before,

didn’t really understand why it was there, to see this lady on the floor was like, it

was horrific. I’d gone home and I’d talked to my partner and I said, ‘I don’t want

to go back’. I said, ‘I don’t know if I can do that’, but I did.

(Joanne: care manager)

Within Joanne's narrative, at first, she considered resigning from her new position after

witnessing a restraint, but her attitude to restraint changed and the process of normalisation

occurred within her narrative. Joanne did not report observing service user/survivor violence

until starting to work in this institution. Within her narrative, there seems to be an interesting

change between her experiences of working in smaller residential care units where restraint

was not used to larger psychiatric hospitals where restraint appeared to be normal practice.

Within her narrative, she individualised the characteristics of service users/survivors in that

particular institution as ‘risky’ and ‘violent’ to justify the use of restraint:

Very challenging behaviour, yeah, it was the place where I was at for people who

would be considered a danger in the community. … They had their own rooms,

personalised rooms, had big-screen TVs. So it was a mixture between a hospital

and a home setting.

(Joanne: care manager)

For Joanne, these service users/survivors were conceptualised as inherently violent and their

behaviour needed controlling. From her perspective, the use of restraint bestowed security

and protection to staff and other service users/survivors within this hospital setting. From a

service user/survivor perspective, a number of participants reported being restrained both in

the pre- and post-1983 hospitals. Harry was somewhat representative of service

users’/survivors’ views of why restraint occurs in certain hospitals. From his perspective, the

use of restraint usually occurred to control behaviour within busy (post-1983) psychiatric

hospitals. He described these hospital environments as ‘chaotic’:

[These hospitals are] pretty chaotic and I was glad to get out. I didn’t see it

as a help and I don’t think I got the support. I was glad to get away.’

(Harry: service user/survivor)

Another service user, Jack, also described violence occurring in these often chaotic

psychiatric hospital environments, where he described witnessing the use of restraint

on other patients due to violence. As Jack reported:

Some of the patients could be angry and nasty and the odd one would be violent.

I’d seen people held down and took off the ward to the, it’s called the Picard Ward

now, but it was for people who get violent and stuff like that.

(Jack: service user/survivor)

Within Jack's narrative, he described how violence was often accompanied by the use

of restraint. He also described that patients who are restrained are often transferred to

another ward for a period of time. However, one of the female participants, Donna,

experienced a slightly different practice of restraint from other service users/survivors

as she described that restraint took place alongside solitary confinement. Within her

narrative, she explained how she found this experience particularly upsetting, and from

her perspective, it offered no therapeutic rewards.

Yes [restraint was used] and they locked me in [a room]. I don’t know if that was

in [name of North East hospital] or [name of South East hospital]. … I had to be

locked up because I was being naughty … I had to scream for somebody to come

but I don’t know if they heard us.

(Donna: service user/survivor)

She described the administration of restraint as a system of punishment in order to control

her disruptive behaviour on the wards. Within her narrative, we can observe that Donna was

not only restrained but also confined and isolated for a period after a restraint occurred. She

reported that these experiences were particularly traumatic. From Donna's narrative, this

gives us an example of how restraint and isolation were used in conjunction with each other

as a system of disciplinary control for this service user/survivor.

Coercive Violence and Power

When observing if criminality occurs within institutionalised care settings, practitioners,

service users and family members described examples of coercive and sometimes criminal

violence. It is through the testimonies of practitioners where we can see the clearest

examples of how coercive violence operates and may have affected incidents described by

service users and family members within this study. The most detailed example of coercive

violence is illustrated by Christopher. He suggested that on numerous occasions throughout

his career he had been ‘set up’ by members of staff who manipulated patients for

entertainment purposes or to relieve boredom in a ward.

Deliberately they [senior nurses] left us in charge while they went on their lunch,

but it was meant to be for half-an-hour. They were away for about two hours. So

by the time they came back, we knew we’d been set up because what happened

in that first half-an-hour was that one of the patients who they were very close to,

decided to have a go about who was in charge. ‘I’m in charge, you’re not in

charge!’

(Christopher: mental health nurse)

Throughout Christopher’s narrative, he separated nurses who were committed to the care of

patients from those who he often described as ‘cruel’. He explained that abusive sub-cultures

often emerged on certain wards because of particular uncaring attitudes, and suggested that

particular members of staff were ‘absolutely vicious and cruel’ which resulted in the ‘setting

up’ of scenarios for patients engineered to entertain staff and relieve boredom.

There was people there who brought their own baggage in. So I mean very early

on in my time there as a student nurse, two people tried to show me how to hit

people with wet towels to, you know, you could leave no bruising. … And there

was a guy in there who was a qualified nurse who decided to put some aftershave

onto this old man’s testicles. He was a big guy. So he was known to be aggressive.

… So what happened was that they set this guy up, put this stuff on his balls. He

then came running up the ward, you know, I had to calm him down and

immediately I realised what had happened. So I took him for a bath. I took him for

a bath and I bathed him and he was really kind with me after that.

(Christopher: mental health nurse)

Within his narrative ‘being set up’ by other nursing staff became a prominent feature of abuse

and ‘entertainment’ within the pre-1983 mental hospitals. Christopher described examples

of abuse where service users/survivors and staff were taunted, manipulated, or even

assaulted in these hospitals. He illustrated that these assaults were rarely administered by

the nursing staff but occurred from the manipulation of patients, where scenarios were

created with the intention of coercing patients into carrying out the assaults on other patients

or members of staff. From a service user/survivor perspective there was some evidence of

this form of coercive violence emerging from their narratives. It should be noted that

examples of violence by other patients were discussed by the majority of service

users/survivors in pre- and post-1983 hospitals, and although service users/survivors

described some nursing and care staff as ‘cruel’, no participant reported being physically

assaulted by a staff member. However, Christopher’s account of how coercive violence

operates on the wards may help frame some of the incidents described by service

users/survivors in this study. An example of what may have been coercive violence was

discussed by a female service user/survivor describing an incident concerning other patients

(pre-1983). Donna reported voluntarily putting her head through a window because of the

encouragement of other patients. As Donna states:

These two patients dared me to put my head through the window and I did it. And

I’ve [still] got all the scars on the side of my head.

(Donna: service user/survivor)

Donna could not verbalise why she carried out this act of self-harm and reported that she just

wanted to comply with the wishes of these patients. When describing this act Donna pointed

to the scarring on her head which was still visible many years later. When asked how the

nursing staff responded to this particular act Donna could not recall any repercussions for the

patients who encouraged this act of self-harm. One of Donna's family members, Gloria, also

described this incident within her narrative, yet the coercive aspect was not illustrated as a

central concern; the key emphasis of Gloria’s narrative was on the act of her sister voluntarily

smashing her head through a glass window. From Gloria’s perspective, this act seemed to

illustrate how mentally ‘unwell’ Donna was during this time and at no point was the quality of

care questioned by Gloria. This seems to illustrate the power dynamics and attitudes of trust

between nursing staff/carers, service users/survivors, and family members. As Gloria states:

I don’t know what made her do this, but she said somebody told her to do it so

she did it. Then she put her head through the window at [North East mental

hospital] and that’s why they kept her in longer.

(Gloria: family member)

Gloria reports that a consequence of this act was an extension of Donna's hospitalisation.

Although there is no evidence that this particular incident was instigated by nursing or care

staff, the impact of this incident did not seem to lead to any form of investigation into nursing

malpractice but resulted in further forced hospitalisation for the service user/survivor.

A contemporary example (post-1983) of coercive violence was illustrated by Jack when

sectioned in a psychiatric hospital. Within this example, the coercive aspect of his experience

was not instigated by another patient but by a member of the care team. This experience

intensified his suicidal feelings. As Jack reports:

I mean I had no bother with most of the staff. … But this one staff member come

down, he was pretty abusive. … I was very poorly and he made us a bit suicidal to

be honest. … I’d put in a complaint funnily enough. I just said he’d shouted at us

to one of the other staff members. Another staff member came down and said I

was a liar that I’d just made it up.

(Jack: service user/survivor)

Within Jack's narrative, no physical abuse took place by staff but he does describe these

interactions which he considers abusive and harmful. What differs between Jack’s and

Donna's narratives is that Jack made a complaint to another care practitioner. Unfortunately,

although he made a complaint about this particular staff member, he describes being

dismissed as dishonest. As Jack discusses, this had a significant impact on his mental health

which intensified his suicidal feelings. Similar to Donna, no investigation took place and from

his perspective, his voice was disregarded by the hospital. Jack reports that a consequence of

these staff attitudes and his frustration of being hospitalised resulted in an increase in self-

harm. ‘I used to bang my head off the walls and punch the walls. That was out of anger mostly.’

Similar to Donna’s experiences, his responses to these oppressive practices always led to a

restriction of his privileges or an extension of forced hospitalisation. From his perspective,

hospital and care employees were never questioned and the acts of violence or self-harm

were always conceptualised as symptoms of his ‘illness’.

From a practitioner's perspective, Joanne acknowledged that abusive cultures could emerge

within the contemporary psychiatric hospitals or residential care units similar to those of the

historical mental hospitals. As she suggested:

I mean I would never say that there wasn’t any abuse where I worked, but I could

say there was always potential. I could see how easy the card could be flipped

because of the power that you have with the restraints, with these people being

sectioned, with the locked doors. You know what I mean? I could understand how

that happened down in Winterbourne View. … I think in them environments there

are cultures built up because you were working fourteen-hour shifts.

(Joanne: care manager)

From Joanne's perspective, although she had not witnessed any forms of physical or coercive

violence when working in professional practice, she accepted how coercive sub-cultures could

develop within a care setting. Although she acknowledged that she had witnessed poor

attitudes by staff, she also recognised how these attitudes could develop into forms of

institutional violence. Within her narrative, she referred to the criminal case of Winterbourne

View and conceded the potential for violence occurring within these contemporary

institutions by acknowledging how difficult physical or coercive violence would be to detect.

Discussion

Although the hospital is conceptualised as an environment of care, this article has presented

some evidence that this institution can also be a space where violence and abuse can manifest

itself. Although criminology has very rarely explored the hospital as an institution of harm,

the author suggests that due to recent scandals the psychiatric hospital could in some cases

create a space where criminal and abusive activities can flourish. By examining the

experiences of participants, the data findings reveal small windows of dehumanising harmful

practices and coercive violence that were present both within pre- and post-1983 psychiatric

hospitals. This was particularly exposed in the practitioners’ narratives concerning how

coercive violence arose within pre- and post-1983 hospitals. Interestingly, a number of these

practitioners suggested that underqualified, underpaid, and disillusioned staff, and the size

of an institution, led to the risk of coercive violence within the hospital and residential

environments.

The data findings also portrayed corresponding narratives that emerged from family

members concerning these oppressive practices. Similar to practitioners, family members

were also extremely critical of the use of restraint within hospitals. Yet it should be noted that

even when serious incidents occurred, such as relatives enduring injury, these participants

very rarely questioned the treatment or techniques used by psychiatric professionals. The

findings seem to reveal that family members in this study did not confront the power

dynamics which operated within these hospital environments, even though they sometimes

conceptualised these treatments as oppressive. From a service user/survivor perspective,

most participants described negative experiences that they conceptualised as harmful.

Service users/survivors reported significant feelings of distress relating to forced

hospitalisation, restraint by staff, and violence dispensed by other patients. Thus, although

this study did not reveal many incidents of criminal violence, this article opens up the debate

about whether mental health hospitals may be conceptualised as potential sites of coercion

and harm, as well as care, noteworthy of contemporary criminological investigation.

Implications for Practice

This article illustrates several significant issues that have implications for professional

practice. Firstly, although this study found little evidence of criminal violence perpetrated by

staff towards service users, the data did reveal some evidence of dehumanising and harmful

practices concerning restraint. Key concerns that emerged from the data analysis were

harmful attitudes by certain members of staff and coercive forms of violence within these

institutions. Senior practitioners also raised concerns relating to appropriate levels of training

and the professional commitment of some employees. The author would argue that

privatisation has led to the deprofessionalisation of care staff within these institutions. Thus,

to reduce the chances of violence and social harms within these institutions staff should

require entry qualifications and professional training to work within these highly stressful and

complex environments. Furthermore, to attract employees of this calibre institutions must

reward staff with acceptable pay scales rather than minimum wage salaries, and this may

reduce risk factors associated with the prevalence of violence that emerged in this study.

Secondly, the data revealed that staff in larger institutions were more likely to use restraint

in their day-to-day practices. Over recent years we have seen the growth of larger institutions

housing a greater number of service users for an increased length of time (Burki 2018). Thus,

if mental health services continue commissioning the use of larger residential care homes and

psychiatric hospitals, then history may repeat itself and these contemporary 21st-century

institutions could run the risk of becoming replicas of the historical 19th- and 20th-century

mental hospitals/asylums, which are described by some historians as ‘warehouses for the

mad’ (Shorter 1996).

Finally, this article has applied Disability Theory within a criminological context. By doing this

the data analysis has been guided by service user/survivor voices to interpret and

comprehend experiences of violence and harm. Within the data analysis, similarities and

distinctions were drawn between service users/survivors, family members and practitioners;

however, these different narratives revealed glimpses of criminality, violence, and social

harms within these institutional environments. Therefore, this article advocates for future

criminological research to move away from the biomedical interpretation of disability and

mental health to a critical perspective which is emerging from contemporary scholarship

within Disability Studies and criminology (Dowse et al. 2008; Sherry 2010; Macdonald 2012;

2015; Voronka 2013).

Conclusion

This article has presented data examining violence and harm within mental health services

which is relevant to criminology. The study indicates that contemporary residential care

homes and psychiatric hospitals are not free from violence and social harms. As this study

illustrates, there were a number of examples where violence was prevalent within these

institutions. Thus, the article argues that these institutions are legitimate sites for

criminological investigations into confinement, criminality and its associated social harms.

The study has been theoretically inspired by Disability Studies, and in particular by scholarship

from the sub-discipline of MAD Studies. From a MAD Studies perspective, it is vital to employ

a constructionist framework to critically evaluate aspects of bio-medical oppressive practices

drawn from the lived experiences of service users/survivors and their allies (Faulkner 2017).

As LeFrançois (2013) proposes, by applying a MAD Studies perspective, practitioners can allow

a safe space to bring together service users/survivors to facilitate anti-oppressive ideas

concerning treatments. Hence, the simple task of listening to service users’/survivors’ voices,

and their allies, may give rise to social justice and empowerment for these individuals who

have been made vulnerable to institutional harms and violence within these hospital and

residential settings.

References

Barnes, C. (2020). Understanding the Social Model of Disability: Past, Present and Future. In N.

Watson, A. Roulstone and C. Thomas (Eds), Routledge Handbook of Disability Studies, 2nd Edition.

London: Routledge, pp. 12–29.

Beresford, P. (2004). Madness, distress, research and a social model. In C. Barnes and G. Mercer (eds),

Implementing the Social Model of Disability: Theory and Research. Leeds: Disability Press, pp. 208–

222.

Bertaux, D. (2003). The Usefulness of Life Stories for a Realist and Meaningful Sociology. In R.

Humphrey, R. Miller and E. Zdravomyslova (Eds), Biographical Research in Eastern Europe: Altered

Lives and Broken Biographies. London: Ashgate, pp. 39–52.

Bradley, K. (2009). The Bradley Report. London: Home Office Minister.

Bubb, S. (2014). Winterbourne. View – Time. For Change. Transforming the commissioning of services

for people with learning disabilities and/or autism. London: Department of Health.

Burki, T. (2018). Increase in detentions in the UK under the Mental Health Act. The Lancet Psychiatry.

DOI: 10.1016/S2215-0366(18)30399-7

Chakraborti, N., and J. Garland. (2015). Hate Crime. 2nd ed. London: Sage.

Department of Health. (2014). Winterbourne View Summary of the Government Response. London:

Department of Health.

Cummins, I. D. (2010). 'Deinstitutionalisation; mental health services in the age of neoliberalism',

Social Policy and Social Work in Transition, 1 (2), pp. 55-74.

Dahan, S. Levi, G. Behrbalk, P., Bronstein I., Hirschmann, S. and Lev-Ran, S. (2018). The Impact of ‘Being

There’: Psychiatric Staff Attitudes on the Use of Restraint. Psychiatry Q, 89: 191–199.

Dowse, L., Baldry, E., and Snoyman, P. (2009). Disabling criminology: conceptualising the intersections

of critical disability studies and critical criminology for people with mental health and cognitive

disabilities in the criminal justice system, Australian Journal of Human Rights, 15:1, pp. 29-46.

Flynn M and Citarella V, (2013). Winterbourne View Hospital: a glimpse of the legacy, in Journal of

Adult Protection, 15, 4, pp. 173 – 181.

Filson, B. (2016). The Haunting Can End: Trauma-Informed Approaches In Healing From Abuse And

Adversity. In Russo, J. and Sweeney, A. (Eds), Searching for a Rose Garden: Challenging Psychiatry,

Fostering Mad Studies. Monmouth, UK: PCCS Books Ltd.

Fitgerald, C.T., Hiett, E, Buysee, D.J., Altıntaş, N., Aikman, G. and Fırat, H. (2015). Sleep Apnea in a

Sample of Patients with Treatment Resistant Depression Referred for Electroconvulsive Therapy.

Journal of Turkish Sleep Medicine, 1: 7–10.

Harwood, A. (2019) Whorlton Hall: Advisers quit government review in protest at CQC's handling of

abuse scandal. DOI: 10.1136/bmj.l4368

Jessel, A. and Boulding, C. (2010) Mental: A History of the Madhouse. London: BBC 4 Production.

Johnstone, P. Zolese, G. (2000) Length of hospitalisation for people with severe mental illness.

Cochrane Database of Systematic Reviews. (2): CD000384.

Kafai, S. (2013) The Mad Border Body: A Political In-betweeness. Disability Studies Quarterly, 33(1),

ISSN:1041-5718 (Print), 2159-8371 (Online) [accessed on 5 June 2018 at http://dsq-

sds.org/article/view/3438].

LeFrançois, B.A., Menzies, R. and Reaume, G. (2013) Mad Matters: A Critical Reader in Canadian Mad

Studies. Toronto: Canadian Scholar’s Press.

Lee (2013) Mad as Hell: The object, in LeFrançois, B.A., Menzies, R. and Reaume, G. Mad Matters: A

Critical Reader in Canadian Mad Studies. Toronto: Canadian Scholar’s Press.

Lepping, P., Masood, B., Flammer, E. and Noorthoorn, E.O. (2016). Comparison of Restraint Data from

Four Countries. Social Psychiatry and Psychiatric Epidemiology, 51: 1301–1309.

Macdonald, S. J. (2012). Biographical Pathways into Criminality: Understanding the Relationship

between Dyslexia and Educational Disengagement. DISABILITY AND SOCIETY. 27 (3), pp. 427–440.

Macdonald, S. J. (2015). “Community Fear and Harassment: Learning Difficulties and Hate Crime

Incidents in the North-East of England.” Disability and Society 30 (3): pp. 353–367.

Macdonald, S.J., Charnock, A. and Scutt, J. (2018). Marketing ‘Madness’: Conceptualising Service

users/survivors Biographies in a Period of Deinstitutionalisation. Disability and Society, 33(6): 349–

865.

Martin, J.P. (1985). Hospitals in Trouble. Oxford Blackwell.

Mental Health Act. (1983) 2007. London: Her Majesty’s Stationery Office.

Menzies, R., LeFrançois, B.A. and Reaume, G. (2013). Introducing Mad Studies. In B.A. LeFrançois, R.

Menzies and G. Reaume (Eds), Mad Matters: A Critical Reader in Canadian Mad Studies. Toronto:

Canadian Scholar’s Press, pp. 1–22.

Middleton, H., and Moncrieff, J. (2019). Critical psychiatry: A brief overview. BJPsych Advances, 25(1),

pp. 47-54.

Moeller, S., Kalkwarfa, N., Lücke, C., Ortiz, D., Jahn, S., Först, C., Braun N., Philipsen, A. and Müller,

H.H.O. (2017). Achieving Stable Remission with Maintenance Electroconvulsive Therapy in a Patient

with Treatment-resistant Schizophrenia. Medicine, 96(48): 1–4.

Nuninga, J.O., Claessens, T.F.I., Somers, M., Mandl, R., Nieuwdorp, W., Boks, M.P., Bakker, S.,

Begemann, M.J.H., Heringa, S. and Sommera, I.E.C. (2018). Immediate and Long-term Effects of

Bilateral Electroconvulsive Therapy on Cognitive Functioning in Patients with a Depressive Disorder.

Journal of Affective Disorders, 238: 659–665.

Murphy G. (2019). Whorlton Hall: a predictable tragedy? British Medical Journal. DOI:

10.1136/bmj.l4705.

Oliver M. (2009). Understanding Disability, 2nd Edition: From Theory to Practice. Basingstoke: Palgrave.

ONS (Office for National Statistics). 2011. Census: Ethnic Group, Local Authorities in England and

Wales. London: Office for National Statistics.

Roulstone, A., P. Thomas and S. Balderston (2011). “Between hate and vulnerability: unpacking the

British criminal justice system’s construction of disablist hate crime.” Disability and Society 26 (3), pp.

351–364.

Roulstone A. and H. Mason-Bish (2013). Disability, Hate Crime and Violence. London: Routledge.

Russo, J. and Sweeney, A. (2016). Searching for a Rose Garden: Challenging Psychiatry, Fostering Mad

Studies. Monmouth, UK: PCCS Books Ltd.

Semple, D. and Smyth, R. (2019). Oxford Handbook of Psychiatry (3rd Edn). Oxford: Oxford University

Press.

Shakespeare, T. (2013). Disability Right and Wrongs. 2nd ed. London: Routledge.

Shorter, E. (1997). A History of Psychiatry. Chichester: Wiley and Son, Inc.

Sherry, M. (2010). Disability Hate Crimes: Does Anyone Really Hate Disabled People?. Surrey: Ashgate.

Steinert, T. Sippach, T. and Gebhardt R. P. (2000). How Common is Violence in Schizophrenia despite

Neuroleptic Treatment? Pharmacopsychiatry. 33(3): pp. 98-102.

Steinert, T. Lepping, P. Bernhardsgrütter, R. Conca, A. Hatling, T. Janssen, W. Keski-Valkama, A.

Mayoral, F. and Whittington, R. (2009). Incidence of seclusion and restraint in psychiatric hospitals: a

literature review and survey of international trends. Social Psychiatry and Psychiatric Epidemiology.

V. 45, pp. 889–897.

Slovenko, R. (2003). “The Transinstitutionalization of the Mentally Ill.” Ohio Northern University Law

Review 29 (3): pp. 641–660.

Szasz, T. (2005). “‘Idiots, Infants, and the Insane’: Mental Illness and Legal Incompetence.” Journal of

Medical Ethics 31 (2): 78–81.

Voronka (2013). Rerouting the Weeds: The Move from Criminalizing to Pathologizing Troubled Youth.

in LeFrançois, B.A., Menzies, R. and Reaume, G. (eds) Mad Matters: A Critical Reader in Canadian Mad

Studies. Toronto: Canadian Scholar’s Press.

Walsh, E. Leese, M. Taylor, P. Johnston, I. Burns, T. Creed, T. Higgit, A. and Murray, R. (2002). Psychosis

in high-security and general psychiatric services: Report from the UK700 and Special Hospitals'

Treatment Resistant Schizophrenia groups. The British Journal of Psychiatry. Volume 180, Issue 4, pp.

351-357.